MassHealth Meets with MAO Members at the NESO Annual Meeting

Posted: 12/19/17 12:03 PM

IMPORTANT UPDATE TO MAO MEMBERS

FRIDAY, NOVEMBER 10, 2017

The meeting convened at 10:15 AM and lasted until about 11:30 AM. Present from MH were Stacia Castro, Tracy Chase Gilman and Tuyen Vu. Stacia Castro introduced herself and the other two representatives from MassHealth. Present from the MAO, approximately 35 doctors and about 8 administrative staff from various MH providers’ offices.

Ms. Castro opened the meeting by making attendees aware of the distinction between MassHealth and Dentaquest, the latter being the third party administrator which “does not make the rules, but does have a foot print in most states. As such, Dentaquest has provided input on general practices nationwide.” Ms. Castro stated that the changes made were “not financially driven”, but instead were put in place to reduce incidence of fraud, which in turn would reduce the hardships involved in audits on their end. Ms. Castro acknowledged that the new “quarterly” billing system was not “ideal”, but was put in place as a stop-gap interim measure, to improve the unworkable monthly system that began July 1, 2017. The impetus for this rapid reform was MassHealth’s dedication to preserving the orthodontic program, and the administration “listening and hearing” the issues presented by the MAO Board on behalf of its members. The response: “they felt it appropriate to make the move.” In making this change back to a “quarterly” system, there was a need to figure out how to manage the “units” being billed, (monthly units back to quarterly units). To that end, it was decided that the remaining billing units would be rounded up rather than down. For instance, if there were five monthly units remaining on October 1, the provider would be allowed to bill two quarterly units rather than one, thereby effectively providing six months of coverage for the five remaining months available. Ms. Castro further noted that the goal of MassHealth is to continue to work collaboratively with the MAO to create a redesigned system for global payment, or possibly a new quarterly system which would be an improvement over any previous system. The conversation regarding these options has begun, and next week (11/13-11/17), they will meet with Dentaquest’s clinical staff to discuss options.

***VERY IMPORTANT — PLEASE NOTE: The MAO Steering Committee was promised a preliminary construct via mail by November 20th FROM STACIA/MH, which was NOT PROVIDED by Stacia.

With that said, Ms. Castro shared that it will ultimately be her proposal, (the result of our collaboration) that will be presented to Robin Callahan and Dan Tsai for approval, in order to implement the next iteration of the program, whatever it may be. Robin and Dan are said to be supportive of this improved future.

Following Ms. Castro’s words, the floor was opened for questions and comments.

Throughout the course of the next hour or so, most doctors and billing coordinators present shared their valuable thoughts, insights, concerns and questions surrounding the past changes and submitted requests, as well as expressed hopes for an improved future. Highlights of these conversations include the following, in no particular order:

Each of these changes represents a “billing nightmare” for each office/staff member involved.

These changes are and have been a significant disruption to offices, both financially and staff-wise, and a return to the original quarterly system should be implemented immediately.

There are moral and ethical questions of orthodontists “being put in the penalty box to get up to 8 units of compensation for 8 units of time worked” as a direct result of the delays in billing created by the “roving quarters”.

Ambiguity exists in claims via language used; “anticipated dates of service” requested, and impossible to determine. (Ms. Castro noted that this was not necessary for submission, as this section is not looked at during processing).

The current system is a “Tail wagging the dog” scenario, where changes were made due to fear of audits. What will the focus on the future be?

What happens to loss of revenues from May-October as a result of the switch to monthly? The State needs to pay doctors back.

There is a history since the 80s of failure to pay on time, in full, and it is recurrent, particularly around July 1. This needs to stop.

Technological advances and improvements, such as CBCT utilization, are not covered appropriately, and directives from MH and/or DQ rely on older, inferior methodology for diagnostics in higher level critical care, such as assessing/treating impactions.

MH should work like and pay like other private insurance plans.

Issues with primary and secondary insurances are also a nightmare to manage

Inactive insurances are still creating havoc on the program, as reporting is not up to date.

Discussions regarding the methodology of payment as it relates to timing of the visits, i.e. prospective vs. retrospective.

It was also requested of MH that any future time that they are considering any changes to the system, they need to speak with the MAO prior to finalizing decisions and implementing change.

Retention Visits: At this point, retention visits will remain at 3. Providers lose the additional 2 visits as of July 1

Of particular note were statements from Dr. Mo Rizkallah, founder and President of MOMa, following Ms. Castro’s comments “that in fact, the system was always meant to be interpreted as a prospective payment, rather than a retrospective payment, and the MAO’s first meeting was when MH found out that all orthodontists felt the opposite, and were billing in that way.” We discussed, at length, the urgency to immediately restore a true quarterly system, where billing and payments would again be retrospective in nature rather than prospective, and that the system is fraught with delays as well as potential risk of inadvertent fraud as a direct result of challenges in maintaining continuity of care and current computerized billing systems.

Ms. Castro had noted that it would have been impossible to do this at the November 1 change date, but took a spur of the moment vote of the attendees to determine the desire for that to occur by January 1. We all voted unanimously to make that change happen. Ms. Castro implied that it could be done, and it was pointed out to her that this exact option was presented by Dr. Chase at the last phone conference between the MAO and MH, but was denied by MH without consideration. It was also shared that had the retrospective billing been implemented on November 1, we would likely not be where we were today, as losses realized would have been made up, and there would be no “unaccounted time for which treatment was rendered”. The mention of a system similar to the one which covers pregnancy was brought up by Ms. Castro, in acknowledgment that the care orthodontists provide are similar to a pregnancy term, more so than treatment rendered by general dentists to resolve active caries.

In wrapping up the meeting, the final points brought home were the need to institute immediate change to a retrospective quarterly billing system, while we, the MAO Steering Committee, continues to work together and, collaboratively with MH, to create a system that is more robust, streamlined, and less complicated than any previous iteration of our current system. We feel, for a number of reasons, not the least of which is this historic first-ever, face-to-face open forum meeting between providers at large and the MH administration, that we are making progress in creating a new system of collaboration with the State to deliver quality orthodontic care to some of the most vulnerable patient population.

We sincerely thank all of the doctors and staff in attendance, and look forward to reporting more great news in the future. We believe that the meeting was a success in continuing to move the process towards a better MassHealth Orthodontic Program.